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IMPLEMENTING MULTISECTORAL APPROACHES:

A Preliminary Review of USAID's Experience

Ishrat Z. Husain

Renuka Bery

March, 2002

USAID, Bureau for Africa, Office of Sustainable Development


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Implementing Multisectoral Approaches:A Preliminary Review of USAID Experiences

HIV/AIDS is one of the biggest challenges to development that we have ever faced. Our

response must be Agency-wide. The HIV/AIDS pandemic is not just a health sector issue;it is the business of every officer in every sector in the Agency. It is imperative that

USAID staff in the heavily affected countries consider HIV-prevention programming in

all sectors and not just as part of the missions health programs. The design of activities

in all sectors should take into account the impact of the HIV/AIDS pandemic on human

and institutional capacity in the sector. In countries where the virus is not yet well

established, missions need to be cognizant of risk factors and should take steps to prevent

the spread of the disease. As we expand our efforts, field missions and Washington must

work even more closely to resolve problems, remove barriers to effective implementation

and share lessons learned broadly. There is no time to reinvent the wheel.

Andrew Natsios, USAID Administrator

June 2001

HIV/AIDS is now the leading cause of death in sub-Saharan Africa and affectsgovernments, businesses, communities and families. In sub-Saharan Africa, 28.1 millionpeople are living with HIV/AIDS and in eight of these countries, 20-35 percent ofchildren under 15 have lost one or both parents. According to UNAIDS, the AIDSsituation in Africa has become catastrophic and requires a broader, intensified responsefrom actors at all levels.

Multisectoral Approaches: A Working Definition

For the purpose of this paper and emanating from the discussion at the 1999 ConsultativeMeeting, a multisectoral approach is defined as responses to the impact of HIV/AIDS bydifferent functional or sectoral ministries or agencies. These responses can be intra-sectoral or inter-sectoral. The former typically implies a sectoral specific ministry oragency, such as education, health, or agriculture, assessing the impact of HIV/AIDS onthe sector and undertaking sectoral reforms to reduce the impact and strengthen thesector. The latter, on the other hand, means different sectors working together to reachspecific targets or goals such as in providing care and support and helping in HIV/AIDSprevention.

Purpose of this Paper

The first part highlights the necessity of multisectoral approaches to acomprehensive HIV/AIDS program and discusses the misconceptions associatedwith this approach.

The second part discusses the operational framework and USAIDs promisingpractices in implementing multisectoral activities since 1999.


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Multisectoral Approaches to HIV/AIDS: A Necessity, Not a Choice

Impact of the EpidemicDifferent sectors as well as the economy as a whole are impacted by HIV/AIDS. Thewide ranging impact of HIV/AIDS makes a broad multisectoral approach an imperative.

Economic growth has started to slow down and labor force losses are starting to be felt.Resources are being diverted from savings and investment to social services.

Economic GrowthUNAIDS estimated that when HIV/AIDS prevalence rises to more than 20 percent, grossdomestic product (GDP) can be lowered as much as 2 percent per year. AIDS may lowerSouth Africas GDP by 17 percent or $22 billion by 2010. The Botswana governmentestimates that HIV/AIDS could reduce GDP by 38-42 percent by 2021. In South Africaby 2005, 33 percent of unskilled and semi-skilled workers, 23 percent of skilled workersand 13 percent of highly skilled workers could be HIV positive.

Human Resource CapacityMuch more seriously, HIV/AIDS will erode the scarce human resource base and willmake the prospect of long-term development bleak. In addition to total labor force losses(chart on next page), countries will be losing specialized skills.

Military: In May 2000, 11 percent of Nigerian soldiers in the UNs West Africapeacekeeping force (ECOMOG) were HIV positive.

Utility Companies: Uganda Railway Corporation has experienced a turnover rate of 15percent per year in recent years.

Agriculture: In Zimbabwe, the death of a breadwinner due to AIDS will cut the marketedoutput of maize in small scale farming and communal areas by 61 percent. In Malawi,death rates among employees of the Ministry of Agriculture and Irrigation have doubled,almost all because of HIV/AIDS.

Education: In Zambia, approximately 1000 teachers die each year due to HIV/AIDS,roughly half the number trained annually. In Botswana, 35-40 percent of all teachers areHIV positive.

Health: A 1999 USAID projection estimates that African health systems may lose 20percent of their employees to HIV/AIDS over the next several years.

Industry: At one sugar mill in South Africa and Kenya studies found that 25-26 percentof the workers were infected with HIV.


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Total Labor Force:HIV/AIDS mortality will account for considerable labor force losses

throughout southern Africa as shown in the table below.

Source: UN Africa Recovery from ILO and UN Population Division data

The supply of workers understates their actual availability to perform their jobsdue to absenteeism, fear, and stressful environments. For example, In Namibia,agricultural extension workers spend 10 percent of their time attending funerals.

Resource AllocationHIV/AIDS also distorts priorities within different sectors as well as for the country as awhole. According to UNAIDS, up to 80 percent of hospital beds in Zambia andZimbabwe are occupied by HIV positive patients. For governments, the epidemic posesa number of dilemmas: to spend limited resources on prevention and care or on futureinvestments. Few studies exist that estimate the short- and long-term impact ofHIV/AIDS and provide the basis for developing future growth strategies, planning, andresource allocation.

SummaryAfrican governments are ill-prepared to address the consequences of HIV/AIDS on theeconomy and on different sectors. Thus, countries must develop strategies and programsin all sectors to reduce the negative impact of HIV/AIDS on the economy. Economicmitigation must be an important component of HIV/AIDS programs.

Southern Af r ica :Labor force

losses due to

HIV/AIDS (%)

by 2005 by 2020

Botswana -17.2 -30.8

Lesotho -4.8 -10.6

Malawi -10.7 -16.0

Mozambique -9.0 -24.9

Namibia -12.8 -35.1

South Africa -10.8 -24.9

Tanzania -9.1 -14.6

Zimbabwe -19.7 -29.4


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Multisectoral Program Formulation

A comprehensive HIV/AIDS program should comprise three components:

mitigating the impact of HIV/AIDS on economic development and on differentsectors

providing care and support to affected families preventing the spread of the epidemic

These three components are interrelated and all require the involvement of multiplesectors.

Mitigation:

Mitigation is the set of activities aimed at reducing various sectoral impacts ofHIV/AIDS. Mitigating development and sectoral impacts of HIV/AIDS requiresassessing its impact and planning and implementing appropriate responses. This is themost neglected and yet crucial aspect of an HIV/AIDS program.

The most direct impact of HIV/AIDS mortality and morbidity is on families andcommunities. This extends to reduced sectoral output and GDP. Actions to break thevicious cycle are required at all levels, but actions at the sectoral level may have the mosteffect because they provide services to households and generate output for the economy.

(See chart on facing page.)

The key actions in mitigating the impact are:

Assessing the long-term impact of HIV/AIDS on development and includingHIV/AIDS in the development planning process and developing new growthstrategies.

Assessing the impact of HIV/AIDS on different sectors and businesses in terms ofmanpower and management and preparing responses by sector to mitigate theimpact and retain or improve output levels.

Assessing the impact at the household level and the existing coping mechanismsin order to improve these and reduce the stress at the community level.

Mobilizing and allocating resources in line with priorities in the economy as awhole and in each sector.


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Care and Support:

Care and support of the affected families and communities especially of the orphans and

those taking care of the orphans will be the greatest challenge for decades to come forcountries with high prevalence. Care and support will require food security, continuingsource of income, sustained agriculture output, education of children, basic health careand housing. Thus each of the sector dealing with these services will have to developoutreach capacity to provide adequate level of services. For effective care and support,coordinated and concerted actions will be required by different sectors.

The key actions are:

Developing mechanisms to provide the resources to communities without delay. Establishing a rapid response system to help affected families and communities in

a timely manner.

Ensuring that a package of at least minimum care is available to all households.


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Sectoral Outreach Needs for

Care and Support


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Prevention:

Preventing new infections requires changes in the determinants of risky behavior. Strongsectoral interventions to reduce poverty and inequality as well as provide care andsupport can lead to behavior change and reduce new infections.

A number of development policies and programs influence the social behavior ofindividuals that lead to or enhance the risk of HIV/AIDS infection as shown in the charton the facing page.

Most HIV/AIDS programs address the symptoms of risky behavior and not the factorsleading to or enhancing risk. Thus, a whole package of policies and programs are neededto influence all risk factors both in the short and long term. Policies and programs indifferent sectors are needed to:

Reduce inequities in economic and social power through girls' education,measures to empower women.

Provide services and facilities for the mobile population to reduce theopportunities for risky social behavior.

Expand employment opportunities for high-risk youth groups through all types ofmeasures including expansion of the private sector and microenterprises.

Access to information and services on safe sex and desensitization anddestigmitization of these issues.

Summary:As this section has shown, mitigation, care and support, and prevention are vitalcomponents of a comprehensive HIV/AIDS program and form a continuum. Each sectormust play three important roles: contribute to total output of the economy, provide careand support, and reduce high risk factors. Economic mitigation of HIV/AIDS willpositively impact care and support as well as prevention efforts while prevention willreduce the need for mitigation efforts.

HIV/AIDS CONTINUUM

Prevent ion Economic Mi t iga t ionCare and Support


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Myths and Misconceptions about Multisectoral Approaches:

A number of myths about multisectoral approaches exist that need clarification tofacilitate the adoption of these approaches. These are discussed below:

Myth #1: Multisectoral approaches are interpreted to mean a private-publicpartnership in responding to the epidemic. While this partnership is vital forimplementing multisectoral programs, this is actually a multi-agency response.

Myth #2: Each sector has to undertake core HIV/AIDS prevention functions, e.g.condom distribution, conveying core HIV/AIDS messages. This is not the case.Different sectors must address the HIV/AIDS activities that could be part of their normal

program. For example, an education ministry has to cater to educational needs of orphansand could include HIV/AIDS education as part of its life skills courses. Similarly,agriculture extension workers might need to change cropping patterns in view of theshortage of labor or sickness in households.

Myth #3: HIV/AIDS activities undertaken by non-health sectors might erode theexisting weak implementation capacity in that sector. HIV/AIDS is already erodingthe capacity of different sectors. Thus, the HIV/AIDS activities that different sectorsshould undertake are geared toward mitigating the impact of HIV/AIDS on the sector.This provides an opportunity to address deep-rooted systemic issues in the sector.

Myth #4: Multisectoral approaches complicate the HIV/AIDS program and weakenits ability to focus on core interventions with a track record of success. In fact,multisectoral approaches will strengthen core interventions (condom distribution, socialmarketing, VCT, MTCT) by involving different sectors that provide additional channelsfor HIV/AIDS awareness and behavior change. Multisectoral approaches do not requirelarge amounts of funds and will not divert resources from core interventions.


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Success of Multisectoral Programs:

Most successful population programs such as in Bangladesh, Indonesia, Tunisia andThailand were multisectoral. The same phenomenon is emerging in HIV/AIDS. Thesuccessful program in Uganda has adopted multisectoral approaches.

Uganda

Strong political leadership has been the hallmark of Uganda's success in curbing theHIV/AIDS epidemic since the late 1980s. In 1993, the government adopted theMultisectoral Approach to the Control of AIDS, which served to coordinate theHIV/AIDS activities of 12 separate Ministries, followed by the 1994-98 NationalOperational Plan for HIV/AIDS/STD Prevention, Care and Support.

The National Strategic Framework for HIV/AIDS Activities (2000/1 - 2005/6) is an

intersectoral plan, involving all relevant Ministries including Health, Labor, Gender,Defence, Education, Information, and Agriculture. The government is pursuing a policyof decentralization with the objective of strengthening local governments andempowering communities to assess and monitor local responses to HIV/AIDS. Theframework mandates that the Ugandan AIDS Commission form a national joint planningteam to be comprised of representatives from government, NGOs, faith-basedorganizations, and the private sector. Each district is directed to establish a District AIDSCoordination Committee.

Factors Contributing to a Successful National Response in Uganda: (30)

President Museveni publicly acknowledged Uganda's AIDS problem andcommitted to mobilizing efforts against it.

A budget for a national AIDS program was established early in the epidemic. Uganda adopted a multisectoral approach to HIV/AIDS prevention. The Uganda AIDS Commission was established. AIDS control programs were established in several government ministries. Political, community and religious leaders became involved in the response. Radio messages on HIV/AIDS were broadcast widely. Condom social marketing, backed by USAID, was implemented

countrywide.


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Operational Framework for Multisectoral Approaches:

An operational framework for USAID to support countries in adopting and implementingmultisectoral approaches emerged from the Consultative Meeting in 1999. Theframework consists of the four components described below.

a. Reduce the impact of HIV/AIDS on economic growth: countries need to assessthe long-term impact of including HIV/AIDS in development planning and todevelop strategies to reduce the negative impact of HIV/AIDS on economicgrowth.

b. Strengthen the management capacity of key sectors (agriculture, education andhealth) to respond to HIV/AIDS. These responses comprise policies andprograms to mitigate the impact on the sector, provide care and support and adoptprevention policies to protect the workforce. The arrows show the intra-sectoralactions to strengthen outreach services of the sectors from national to local levels.

This is an iterative process in which information flows both ways betweengovernmental and non-governmental organizations, and communities. The foursectors shown in the chart are related to USAIDs strategic objectives. However,any number of sectors can be included.

c. Develop and implement inter-sectoral programs to reduce the impact ontargeted communities and groups in a concerted and coordinated manner.The arrows point to the community level or targeted groups in the middle of thechart. The chart shows different sectors working inter-sectorally to provide careand support to the affected families or to address the issues related to riskybehavior among high-risk groups such as youth.

d. Strengthen democracy/participation and governance of various sectoral andinter-sectoral programs to provide services efficiently. USAID's democracyand governance strategic objective, can help bring about better coordinationamong the sectors and mobilize communities and civil society to support inter-sectoral actions.


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USAID Progress on the Implementation of Multisectoral Programs:

This section describes the overall progress by USAID missions and AFR/SD in adoptingmultisectoral approaches, the promising practices in implementing sectoral (arrows ofchart) as well as inter-sectoral (middle circle in chart) components. This section will also

describe the processes adopted by missions that have led to successful implementation ofmultisectoral programs.

Overall Progress

Fifteen country missions have either adopted different components of the aboveframework or developed strategies leading to it. USAIDs HIV/AIDS programs in SouthAfrica and Zambia contain most of the frameworks elements. This section will analyzepromising practices in adopting and implementing different aspects of the framework interms of sectoral and inter-sectoral programs, policy dialogue, and coordinationmechanisms by different missions and AFR/SD.

AFR/SD has provided support to all the strategic objectives (SOs) in its portfolio toincorporate HIV/AIDS concerns. It helped University of Natal to develop, disseminate,and apply toolkits for different sectors. The education SO in AFR/SD has made the mostprogress, followed by Democracy and Governance and Natural Resource Management.

Sectoral Strenthening

Economic Growth: The South Africa Mission has been at the forefront in helping SouthAfrica incorporate HIV/AIDS into the planning process and develop strategies to mitigatethe impact of HIV/AIDS on economic growth. The mission has developed a new growthstrategy that has the potential to reduce risk factors and prevent HIV/AIDS. This strategyincludes generating employment and reducing poverty through private sector growth. Thenew strategy has a two-pronged approach: promoting growth of non-agricultural small,medium, and micro-enterprises in urban and semi-urban areas and promoting the growthof small-scale agribusinesses in rural areas. All Mission strategic objectives haveactivities that contribute to this overarching objective.

The mission provided technical advisors in five ministries to assist in addressingHIV/AIDS issues (Treasury, Education, Public Service and Administration, Housing andHealth). The work of these ministries provides inputs into the planning process.

To stimulate the private sector to take remedial measures the mission funded studies ofthe impact of HIV/AIDS on cost and productivity in large and medium size firms and onsmall businesses.

USAID is experimenting with economic responses to HIV/AIDS for poor communitiesthrough mechanisms of microenterprise development and microfinance. The KenyaMission is funding an experimental approach to pool community financial resources inheavily AIDS-affected areas. In Zimbabwe, the mission is using an agribusiness linkage


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approach to connect AIDS-affected households and communities to economicopportunities, many of which are in export markets. USAID community-mobilizationprograms, such as COPE in Malawi, often include a microenterprise and microfinancecomponent. While these programs receive high marks for community mobilization, theyappear to be generating only modest economic results. These new lessons point to the

need to pursue programmatic linkages between economic growth specialists andcommunity mobilization specialists, to ensure both community results and strongtechnical approaches.

AFR/SD, in preparation for the HIV/AIDS session of a recent AGOA meeting,commissioned four papers dealing with the impact of HIV/AIDS on AGOA objectivesand on the responses of the Ministries of Finance, Trade and Businesses. These papersprovided the basis for determining key actions to be taken by the economic ministries.

Education: The education sector has made the most progress with several countriesgetting involved in planning and implementing a response to HIV/AIDS. Using Africa-

based expertise, USAID has piloted an action-oriented planning model that helpsministries of education to develop a systemic response to the HIV/AIDS epidemic. AMobile Task Team (MTT) has been formed by the University of Natal and countriesinvite the team to help in assessing the impact of HIV/AIDS and developing an actionplan. Planning for the epidemics impact allows ministries to demystify social issuessurrounding HIV/AIDS and enables them to focus on providing quality education.Ministries in Namibia, Malawi, Zambia, and Ghana are implementing MTT-supportedaction plans.

The first country to invite the MTT was Zambia. As a result, the education sector inZambia developed comprehensive strategic and implementation plans for HIV/AIDSmanagement. A new decentralized education management information system is beingdeveloped to collect and use HIV/AIDS-related data. A full-time HIV/AIDS manager isworking at the MOE. Communities are identifying orphans and vulnerable children toensure their access to education.

Health: Almost all health operations in the field include HIV/AIDS activities. However,a recent effort by the Rwanda Mission represents a promising practice. In Rwanda,USAID and the Partners for Health Reform project collaborated with the MOH andWHO to adapt the National Health Accounts (NHA) methodology to analyze specificexpenditures and requirements for HIV/AIDS. To respond to the need for greater equityin access to care, USAID supported the MOH in developing prepayment schemes thatenroll households with persons living with AIDS. As a result, about 10,000 persons withHIV were enrolled in the three pilot districts. This work has been documented as part ofUNAIDS Best Practices series.

Recently AFR/SD, through the University of Natal, initiated the formation of a MobileTask Team in health patterned on successful education efforts. This Team will startworking in a province in South Africa. On the basis of this experience the work willexpand to a couple of other countries.


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Democracy and Governance

The Kenya Mission conducted a formal assessment of the linkages between HIV/AIDSand DG activities and recommended ways to strengthen the collaboration between thesetwo strategic objectives. The assessment team recommended three types of activities. The

first related to USAIDs internal environment, e.g. what Mission management and keystaff could do to manifest a strong commitment to work cross-sectorally. The secondencourages existing linkages among USAIDs partner organizations. The third seeks tocreate new linkages where few or none currently exist.

AFR/SD developed a compendium of 16 toolkits in the area of democracy andgovernance that address such problems as: the threat of HIV/AIDS to human rights;unorganized constituencies for reform; weak service and advocacy capacity; and poorinformation flow. The toolkits have been discussed in Zambia and Ethiopia and projectpartners have committed substantial funds for applying the components of the toolkit.

Natural Resource Management

The Madagascar Mission has developed an innovative program that links health,population and environmental interventions. Collaborators work in villages nearthreatened, biologically diverse ecosystems. Improving access to health services is anincentive to adopt new agriculture and natural resource management techniques thatrelieve the pressure on the fragile forest corridor. In Zambia, an agro-forestry project hasincorporated HIV/AIDS prevention messages into seed distribution activities thusfacilitating HIV/AIDS education and communications with traditionally hard to reachcommunities.

The AFR/SD environment and NRM teams efforts focus on both exploring the nature ofthe relationship between HIV/AIDS and the sector, and providing ministerial levelprofessionals and sectoral planners and managers with tools to take proactive measures tomitigate the HIV/AIDS crisis in the field.

One venue for exploring further cross-sectoral mitigation activities would involveincorporating HIV/AIDS impact assessments in the environmental review process forprojects across all sectors. A toolkit and brief has been developed for this purpose.


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Intersectoral programs

The best example of intersectoral program is the care of the orphans provided through theCommunity-based Options for Protection and Empowerment (COPE) project in Malawi.This project works with local residents to form or reform and mobilize district, subdistrict

and village AIDS committees, which provide sustainable community action to preventand mitigate the impact of HIV/AIDS.

Through COPE, communities develop a sustainable "package" of services for HIV/AIDSprevention, care, and mitigation that addresses the needs of AIDS-affected familiesholistically, including those of orphans and other vulnerable children. COPE's success isdue in part to its inclusion of assistance for a whole range of responses on the HIV/AIDSprevention-to-care continuum, so that villages are not forced to artificially separateprevention from care, the infected from the uninfected, adults from children, or malesfrom females in their responses.

After developing basic capacities of leadership and organization, COPE-assisted VillageAIDS Committees initiate support for orphans and their guardians, home care services forthe chronically ill, prevention programs, services for young people, and economic andfood security programs through their sub-committees. Thus, villages develop a wholerange of services to protect and support orphans and other vulnerable children startingbefore they are orphaned and continuing through their life cycle. The capacity of thevillage as a whole is improved through the COPE model so that AIDS-affected childrenand families are not isolated or stigmatized.

COPE is demand driven because it is modeled on traditional, community-based multi-sectoral strategies developed in response to the HIV/AIDS epidemic in Malawi. COPEstrengthens community safety nets and enables the community to deal with the effects ofthe epidemic.

However, when the size of COPE's service population (9%) and those of projects like it isput against the extensive need for community-based HIV/AIDS projects all across sub-Saharan Africa, it is clear that they form only a small microcosm of effectiveintervention. Full-scale replication in Malawi relies on coordination and development ofbetter interfaces among organizations with technical skills and organizations with theresources to overcome the constraints of abiding individual and institutional poverty.

USAID has developed a new program to improve reproductive health services for youththat is being implemented in selected countries in Africa. In addition, AFR/SDcommissioned a study on youth livelihood that provided a framework for assessing andlinking youth livelihood and HIV/AIDS activities. AFR/SD also prepared guidelines fororphan care and for care and support in general.


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Processes for Implementing Multisectoral Approaches

Processes: The processes that lead to adopting multisectoral programs are important.These include policy dialogue with countries on the adoption of multisectoral programsand on the establishment of organizational structures and funding. The best practices in

this regard are highlighted below.

Country Policy Dialogue: The Tanzania Mission, along with other donors, effectivelyconvinced the government to establish the Tanzanian Commission for AIDS, located inthe Presidents office. The commission consists of representatives of various ministriesand has improved multisectoral programs.

Coordination Mechanism: Zambias multisectoral HIV/AIDS program operates at boththe national and district/community levels. This two-tiered approach, supported by themission, is based on the conviction that only through participatory approaches with localcommunities and the government can programs be sustainable. The multisectoral

HIV/AIDS program seeks the most cost-effective methods to mitigate the impact ofHIV/AIDS by emphasizing collaboration and sharing of material and technical resources.

This program is managed by the HIV/AIDS and Orphans Working (HOW) Group,comprised of strategic objective and program office leaders, and the multisectoralHIV/AIDS coordinator, who also acts as a liaison to district implementers. In 2001, theHOW group selected Livingstone as a pilot district to implement multisectoral activities.

Funding: It is hard to estimate the amount spent on multisectoral activities by theMission. However, the South Africa Mission has provided substantive amounts to othersectors. AFR/SD also gave a modest amount for HIV/AIDS work to the education anddemocracy and governance SOs.


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Future Directions

On the basis of USAIDs experiences of over two years in multisectoral work thefollowing points need to be considered in setting future directions:

Greater focus on sectoral reforms: Each sector is critically important to the economy as awhole and for providing care, support and prevention. Thus, each sector needs to addressHIV/AIDS issues in a systematic manner. Education has provided an important model.Toolkits and briefs are available to guide the process.

Sustainability of inter-sectoral efforts is linked to sectoral strengthening: The inter-sectoral activities at the community level, whether related to microenterprise or orphanand youth care, are successful and sustainable if national- and local-level sectoralagencies provide adequate support. Therefore, sectoral strengthening is essential for inter-sectoral activities.

Champions are the key to success: To date, sectors that have shown progress and results

had champions who tried to mobilize resources and make special efforts to addressHIV/AIDS issues in that particular sector. Hard data on the impact of HIV/AIDS on thesector are necessary to generate the type of commitment necessary for someone to takeup the cause. Therefore, supporting special studies to determine the impact in each sectorwill by helpful. In addition, champions need financial support to undertake the necessaryactions.

Coordinated and Concerted Efforts will make a Difference. Multisectoral efforts require astrong coordination mechanism for various sectors to work together to obtain synergy. Inaddition, concerted efforts by different sectors will yield results. This again requiresdifferent sectors to have common target areas or groups in which to work. Similarly, in

view of funding shortages, coordination among the donors for multisectoral work will beimportant.

Funding: HIV has a serious impact on all sectors so each sector must set aside funds fromtheir regular development assistance funds to support key activities that can improvesector performance. In this age of shrinking funds, however, not all programs oractivities have to be expensive or out of reach to various sectors. This section describesthree different types of funding streams that can be used for multisectoral approaches.

Implement low cost initiatives: Addressing the risk factors of the disease might notrequire huge investments in funds. Changing policy should not require huge investments

of funds; rather, gathering enough evidence to introduce and support policy change isrequired. Such policy changes would serve to improve the overall performance of thesector and would as such be funded from the current sectoral budget.


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Shift activities to high prevalence areas: In some countries, different regions orcommunities are more vulnerable to HIV/AIDS than other sections of the population.This funding approach suggests shifting resources to areas where HIV prevalence is highto strengthen the sectors in that area.

Access HIV/AIDS funds for certain activities:The U.S. government has set asideHIV/AIDS monies from the CSD fund that may be used for activities that are specificallyrelated to HIV. The types of activities include HIV/AIDS training, assessing the impactof HIV/AIDS on a sector, providing HIV/AIDS information or designing HIV/AIDScurricula, providing HIV/AIDS services such as testing, counseling and drugs, anddeveloping programs that directly support HIV/AIDS prevention, care and supportprograms.

Illustrative list of permissible activities using CSD funds

A tentative list of activities that each sector could undertake is given in the Annex. Theseactivities lend themselves to the type of classification mentioned above. Each sector can

undertake at least a minimum number of activities with modest funds.

Training personnel to provide HIV/AIDS prevention and care; Assessing the impact of HIV/AIDS on a particular sector; Generating commitment among senior government officials and other leaders

to initiate policy dialogue and/or change in regard to providing information onHIV/AIDS;

Initiating HIV/AIDS activities or programs for youth, agriculture workers,teachers, etc.;

Adding HIV/AIDS education or service components, such as voluntarycounseling and testing, to programs (employment generation, education,agricultural, etc.;

Supporting the drafting of national HIV/AIDS policies with government orNGO groups including drafting and promoting legislation and regulationwhich protects the rights of people living with HIV/AIDS;

Protecting workers (agricultural, education, etc.) from the spread ofHIV/AIDS;

Providing workers with training in HIV/AIDS information and prevention; Developing public service announcements or special programming on

HIV/AIDS for television, radio or the print media.


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Annex 1

Effective Practices

Planning for Economic Growth

South Africa Mission

The Economic Capacity Development SO in collaboration with Health SO in the SouthAfrica Mission has made impressive progress in dealing with economic aspects ofHIV/AIDS and can be considered a model for other USAID missions. The work beingdone immediately supports the needs of the strategic objectives of Housing/Environment, Employment and Democracy and Governance.

Reduce Economic Disparities and Poverty: The objective of the SO is to improve thecapacity of governmental and non-governmental entities to formulate, evaluate andimplement economic policy. The SO promotes active involvement of historicallydisadvantaged (i.e. black) South Africans in policy-making and implementation tosharpen the focus on job creation, redressing socio-economic disparities and restructuring

the economy to meet the aspirations of all South Africans.

The Mission developed a new growth strategy that has the potential to influence factorsthat will prevent HIV/AIDS such as employment generation and reduction of povertythrough private sector growth. The new strategy has a two-pronged approach: promotinggrowth of non-agricultural small, medium and micro-enterprises (SMMEs) in urban andsemi-urban areas and promoting the growth of small-scale agribusinesses in rural areas.All Mission strategic objectives have activities that contribute to this overarchingobjective.

The Mission supported the establishment of 23 village banks in rural areas, initiated

training activities to support the increased viability of 6,000 microenterprise/microfinanceinstitutions and launched a new microfinance program in townships. USAID has beenproactive in supporting HIV/AIDS prevention activities in all small and microenterpriseprograms and in using such programs to mitigate the many economic problems fosteredby the disease.

Incorporating HIV/AIDS in Development Planning: The Mission in South Africa assiststhe National Treasury to determine the impact of HIV/AIDS on the countrysdevelopment plan and on budget needs over the medium-term. USAID commissioned aseries of studies on the diseases impact on the construction and housing industries, smallbusinesses, agriculture, and local governments. A longitudinal study in one province is

examining the impact of the pandemic on savings and spending patterns.

The Mission provided technical advisors in five key ministries to assist in addressingHIV/AIDS issues (Treasury, Education, Public Service and Administration, Housing, andHealth). The work of these ministries provides inputs into the planning process.

Private Sector: To stimulate the private sector to take remedial measures the Missionfunded a study of the impact of HIV/AIDS on cost and productivity in the private sectorusing seven large firms in South Africa as case studies. Next, the research will try to


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determine the cost-effectiveness of different treatment protocols at larger firms and usethe results and methodologies to assist smaller firms in mitigating the impact. TheMission also funded a study of the HIV/AIDS impact on high-growth small and mediumenterprises as these types of businesses have the potential for generating employment.The results showed that these firms are aware of the disease, how it is spread and that itkills, but they did not view HIV/AIDS as impacting their own business (until the study

pointed out that the disease accounted for the increase in illnesses, deaths, recruitment,medical premiums).

In order to take advantage of African Growth and Opportunities Act, the Mission workedclosely with the American Chamber of Commerce to launch USAIDs GlobalTechnology Network. The program matches business opportunities and technology needsof small companies in the developing world with those in the U.S.

The overwhelming majority of USAID/South Africas HIV/AIDS funds are used fordirect interventions. So, the work by most other sectors on how to mitigate the impact ontheir objectives was funded by non-HIV/AIDS funding accounts.

Results

Impact of Studies: The Minister of Finance in his budget speech noted that the analyticalwork (USAID-supported studies) convinced him to increase the financial allocation forHIV/AIDS. The studies of the private firms have resulted in improved work placepolicies and programs and helped USAID/South Africa sharpen its focus on getting themessage out to business and not just to individuals. The housing work will enable theHousing Ministry to determine how to change the product being provided to low-incomepeople due to the increase in the number of orphans, as well as to determine whether theincrease in poverty will counteract the increase in deaths among the poor to reduce orincrease overall demand. The South Africa Mission has worked closely with governmentdepartments to assure that these studies are used by decision makers. USAID has alsoinvolved various donors to carry forward the agenda for analytical work.

New Growth Strategy: The new strategy resulted in $57.8 million in business transactionsand had significant impact on employment creation. Approximately 4,000 new jobs canbe attributed to these efforts.

HIV/AIDS will have a major impact but the economy is still projected to grow, andaverage incomes will actually grow slightly faster. But, growth is less than it would havebeen otherwise.

AFR/SD Activities

AFR/SD, in preparation for the HIV/AIDS session of a recent AGOA meeting,commissioned four papers dealing with the impact of HIV/AIDS on AGOA objectivesand on the responses of the Ministries of Finance, Trade and Businesses. These papersprovided the basis for determining key actions to be taken by the economic ministries.The four papers are titled: 1.How Does HIV/AIDS Affect African Businesses? 2.How AreFinance and Planning Ministries Responding? 3.How Are Trade and CommerceMinistries Responding? 4.How Are Businesses Responding?


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Strengthening Democracy and Governance

Kenya Mission

The Kenya Mission took the lead in organizing a team in June 2001 to help identify

opportunities for closer collaboration between the Missions DG and HIV/AIDSprograms. The team made three clusters of recommendations. The first level relates toUSAIDs internal environment, e.g. what Mission management and key staff could do tomanifest a strong commitment to work cross-sectorally. The second level is to encourageexisting linkages among USAIDs partner organizations. The third level is to create newlinkages where few or none currently exist. The team also suggested illustrative actionsfor each cluster.

i) Within the USAID Mission

Priority actions

Form a Mission DG-HIV/AIDS working group mandated by senior Missionmanagement

Designate a person from each SO to be a cross-sectoral focal point Include progress of DG-HIV/AIDS working group as a regular item reported at the

weekly senior staff meetings

Expected Results

Cross-sectoral collaboration institutionalized within the Mission to promote DG-HIV/AIDS linkages

An inventory produced of current DG and HIV/AIDS partners activity sites,thematic areas of mutual interest, and potential areas for linkages

ii) Encourage existing linkages among partners

Priority actions

Promote collaboration between current implementing partners Policy Project(HIV/AIDS SO) and State University of New York (DG SO) to strengthen the DGaspects of KANCOs (Kenyas NGO consortium) work with member organizationsand communities, and to coordinate engagement with parliament on HIV/AIDS issues

Facilitate a forum for partner DG and HIV/AIDS groups to promote mutualunderstanding and information exchange

Expected Results

Additional skills needed by each sector identified and addressed Best practices and common tools, such as successful community mobilization

activities and effective means for engaging civil society, documented and sharedamong sectors

DG programs are focused on HIV/AIDS issues when appropriate HIV/AIDS programs are stronger with inclusion of additional DG principles


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iii) Create new linkages among partners

Priority actions

Promote better donor collaboration specifically across sectors Identify additional financial resources (other donors, core funds, foundations, etc.)Expected Results

[specific results will depend upon which actions are undertaken and which partnersare engaged]

Increased technical and financial resources targeting cross-sectoral DG-HIV/AIDSactivities.

AFR/SD Activities

The Democracy and Governance (DG) team in the Africa Bureau developed a toolkit thatapplies democracy and governance principles to fight HIV/AIDS in Africa. This toolkit,Survival is the First Freedom, evolved from the Consultative Meeting on HIV/AIDS inSeptember 1999, and the establishment of a DG-HIV/AIDS technical working group. Itbecame apparent that if civil society groups were to be effective players in the fightagainst AIDS, they neededat a very minimumto avail themselves of proven tools andtechniques that would be widely available in a toolkit format.

Consultations with field staff from around Africa and Nepal produced a compendium of16 tools in March 2001. The tools address various problems such as (1) the threat ofHIV/AIDS to human rights; (2) unorganized constituencies for reform; (3) weak service

and advocacy capacity; and (4) poor information flows. At a workshop in September2001, NGOs, faith-based groups, government, private sector, and donor representativesaffirmed that the tools would help Zambian communities voice the unspeakable, ensurewider participation of women in support networks for AIDS victims, and spread themessage that freedom from HIV/AIDS is a human right.

Results

While the tools were developed by USAIDs $100,000 grant funded from HIV and DGbudgets, the alliance between SD and Pact helped leverage an additional $355,000 tofight HIV/AIDS in Africa.


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Education

Zambia Mission

HIV/AIDS is a major development problem in Zambia. In 2000, the Ministry of Health

estimates that the HIV adult prevalence rate in Zambia was almost 20 percent. Thecountry has an exploding number of orphans due to AIDS which means children leaveschool to engage in income generating activities to support families. Moreover, inZambia about 1,000 teachers are dying each year, about half the number that are trained.

Through 1999, HIV/AIDS had a low profile in the Ministry of Education and its BasicEducation Sub-Sector Investment Programme (BESSIP). In early 2000, the MOE issuedan official statement on HIV/AIDS and how it must form an integral part of educationactivities. The MOE appointed an HIV/AIDS focal point to BESSIP who attended theUSAID-sponsored HIV/AIDS conference in Durban; there he learned how to use thetoolkit for mitigating the effects of HIV/AIDS on education. With AFR/SD and mission

support, the mobile task team for education (MTT) from the University of Natal held aseries of planning workshops with the MOE to develop HIV/AIDS Education annualwork plans. In March 2001, the MOE published a document called, HIV/AIDSPrevention Care and Support: Teachers Guide. It indicates how HIV/Education programswill be implemented through the relevant line departments and BESSIP. The Deputychief inspector of schools serves as the HIV/AIDS focal point, assisted by a full-timeHIV/AIDS officer who is also a curriculum developer.

Results

Zambia Education sector developed comprehensive strategic and implementationplans for HIV/AIDS management

USAID and DFID are collaborating with the MOE on adapting a newdecentralized education management information system (EMIS) to collect anduse HIV/AIDS-related data

DFID is now funding a full-time HIV/AIDS manager at the MOE USAID is helping to mobilize communities to identify orphans and vulnerable

children (OVC) and ensure their access to education and other services

USAID is helping to address equity in girls education Life skills curriculum has been adapted for radio to target out-of-school youth Support is being given to community schools to enroll OVCs.

AFR/SD Activities

AFR/SD supported the University of Natal to develop the toolkit for addressingHIV/AIDS in a number of sectors including education. Using Africa-based expertise,USAID, through University of Natal, has piloted an action-oriented planning model thathelps ministries of education develop a systemic response to the HIV/AIDS epidemic.The model is now being adapted for other sectors such as health. Planning for the


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epidemics impact allows ministries to demystify social issues surrounding HIV/AIDSand enables them to focus on providing quality education. The essential elements of thismodel that is implemented by a Mobile Task Team or MTT are:

The team of African experts is called in at the request of the Government or specificministry such as education;

The team (health economists, physicians and education managers) works directlywith ministry staff;

With MTT facilitation, ministry staff develop a shared understanding of HIV/AIDSimpacts on the education sector and inventory responses that are currently underway;

With this information, the MTT and ministry develop a systemic implementation planbased on prioritized needs;

The action plan is a tool for ministries to manage activities and attract new funds.The plan helps to identify needs and eliminate duplicative funding;

The MTT also builds systemic management capacity for education systems in anHIV/AIDS environment through regional training activities;

The MTT has developed management and training tools for ministries to use, such asa model to project teacher supply/demand, and monitoring and evaluationframeworks.

Results

Ministries in Namibia, Malawi, Zambia, and Ghana are implementing MTT-supported action plans.

Work has begun in Ethiopia, Guinea, and South Africa and is planned for Mali andUganda.

MTT has worked with DFID and the World Bank in Nigeria.


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Agriculture and Natural Resources Management

Mission Activities

At missions across the continent, the environment and NRM sector has been responding

to the HIV/AIDS crisis. In Guinea for example, local NGO staff and governmentservices agents involved in implementing NRM projects have received HIV/AIDSeducation. In Namibia, USAID projects are teaching the CBNRM Living in a FiniteEnvironment (LIFE) project about relevant HIV/AIDS information, and providingHIV/AIDS services to LIFE community groups. The project is also hoping to receivecounseling and testing services for their CBNRM partners. In Zambia, one USAID-funded agro-forestry project has incorporated HIV/AIDS prevention messages into seeddistribution activities thus facilitating HIV/AIDS education and communications withtraditionally hard-to-reach communities.

In South Africa and Ethiopia, HIV/AIDS mitigation has been incorporated into

agriculture projects. In Ethiopia, one USAID project is using agricultural cooperativesas a social marketing outlet for condoms. In South Africa, USAID is supporting aproject to assess the feasibility of linking small and mid-sized permaculture gardens withhealth clinics to allow the income gained from gardens to be used at clinics to help thosewith HIV/AIDS.

AFR/SD Activities

AFR/SD's agriculture SO has developed an analytical agenda that focuses on exploringthe linkages between nutrition and HIV/AIDS.

The environment and NRM team has responded to the HIV/AIDS crisis by providingsector professionals with the tools they need to implement responses to the HIV/AIDScrisis in the field, and supporting research to better understand the relationship betweenHIV/AIDS and the sector.

While it is certain that the HIV/AIDS crisis has had an impact on the environment andNRM sector, the nature and extent of the impact has yet to be fully explored. Theenvironment and NRM team is involved in research projects to understand thisrelationship better. A recent study focused on the impacts of HIV/AIDS on NRM andconservation efforts in Botswana, Kenya, Namibia, Tanzania, and Zimbabwe. Anupcoming project hopes to explore the potential for using GIS as a tool for analyzing therelationship between HIV/AIDS and the environment. By supporting these efforts, theenvironment and NRM team hopes to contribute to the understanding of the relationshipbetween HIV/AIDS and the environment.

The office has also developed materials to incorporate HIV/AIDS mitigation into sectoralactivities. The Community-Based Natural Resource Management (CBNRM) Brief andToolkit were developed as part of a series of sector-specific briefs and toolkits. Thetoolkit was developed for professionals within ministries that have a CBNRM mandate.


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It provides a methodology for understanding how HIV/AIDS is impacting the sectorsassociated with the ministry, and identifying opportunities to help integrate HIV/AIDSprevention and mitigation into their policies and programs. It presents CBNRMprofessionals a framework to assess the impact of AIDS on their project area, and offersproactive steps they might take to mitigate the AIDS crisis.

The environment and NRM teams efforts focus on both exploring the nature of therelationship between HIV/AIDS and the sector, as well as providing ministerial levelprofessionals and sectoral planners and managers with tools to take proactive measures tomitigate the HIV/AIDS crisis in the field.

Results

While successes have been made in incorporating HIV/AIDS mitigation efforts intoprojects across sectors, more progress could be made on this front. One venue forexploring further cross-sectoral mitigation activities would involve incorporating

HIV/AIDS impact assessments in the environmental review process for projects acrossall sectors.

The environmental review process is designed to examine all new development activitiesfor their potential negative impacts on the environment and on human health and welfare.Increased transmission of HIV/AIDS is clearly a potential human health impact andtherefore falls well within the scope of environmental review. Nevertheless, HIV/AIDStransmission is not yet a factor that is regularly considered in the preparation ofenvironmental assessments within USAID and other organizations. The environmentalreview process could become a useful tool in identifying potential HIV/AIDS impactsand mitigation measures before projects are implemented.


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Health Sector Activities

The 1999 consultation on AIDS as a development crisis in Africa noted that theincreasing number of HIV/AIDS cases in hospitals most heavily burdens the healthsectors whereas the health sectors in most countries in Africa are in a state of near

collapse. Health sector reforms are under way in many countries, but the impact of thesereforms on HIV/AIDS program needs to be reviewed. Of special concern is the shortageof trained health workers. The process of integrating HIV/AIDS into reproductive healthprograms is continuing with special emphasis on adolescent health.

Mission Activities

In Rwanda, PHR collaborated with the MOH and WHO to adapt the National HealthAccounts (NHA) methodology to allow for analysis of HIV/AIDS specific expenditures.The findings revealed that HIV places an exceptional financial burden on households ofpersons living with AIDS and that treatment of HIV related illnesses heavily taxes the

health care system. Currently, about 7 percent of total expenditures on HIV go to

prevention of HIV/AIDS, while almost 80 percent pay for treatment of HIV-relatedillnesses. With donor and government spending going mostly towards preventionactivities, 93 percent of health monies for treatment come from out-of-pocketexpenditures. The analysis also revealed accentuated inequities in the use of andexpenditures on health services to treat HIV/AIDS. To respond to the need for greaterequity in access to care, USAID supported the MOH in developing prepayment schemesthat enroll households with persons living with AIDS. As a result, about 10,000 personswith HIV were enrolled in the three pilot districts. This work has been documented aspart of UNAIDS Best Practices series.

In South Africa, a study of the economic impact of HIV/AIDS on the education andpublic service sectors was conducted. Findings indicate that HIV/AIDS will profoundlyaffect manpower available in each sector and the ability of these sectors to provideservices in light of the demands caused by HIV/AIDS. These findings will be used toplan with sector managers at both national and provincial levels to develop andimplement strategies for action, based on the best and worst case scenarios providedby the study.

In the age of decentralization of health services to district level, additional challenges areevident in treating and preventing HIV/AIDS. In Senegal and Ethiopia, USAID is tryingto help the government adequately plan to integrate HIV/AIDS activities into the deliveryof HIV services at the district level.

In Zimbabwe,two separate research and evaluation activities were conducted concerningquality improvement in HIV/AIDS service delivery. At several Voluntary Counselingand Testing (VCT) centers across the country, a mystery client study was conducted toassess client satisfaction with daily operations and the effectiveness of new Rapid TestKits (RTK) in determining HIV/AIDS infection in blood specimens collected atcounseling visits was evaluated. The results of the mystery client study will assist VCT


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managers and staff to improve daily operations and interactions with clients, while theRTK evaluation results suggest that introducing and using these kits will improve theeffectiveness of HIV/AIDS diagnosis and counseling at all VCT centers.

AFR/SD Activities

AFR/SD and other international partners are supporting a meeting to develop nationalHIV/AIDS action plans for West African armed services and to get the region to agreejointly on an action plan that addresses armed forces operating within and outsidenational borders, especially peace keeping missions (ECOMOG).

AFR/SD commissioned two papers on the impact of HIV/AIDS on human resources inthe health sector,Impact of HIV/AIDS on the Health Sector: The Issue of HumanResources and The Health Sector Human Resource Crisis in Africa: An Issues Paper.These papers are being used to highlight the gap between supply and demand of humanresources in the health sector and the need to strengthen human resources to strengthenthe health system.

Results

AFR/SD has also been at the forefront in defining maternal-to-child transmission(MTCT) and HIV/AIDS and nutrition issues. Two papers,HIV/AIDS and Nutrition andPrevention of Mother-to-Child Transmission of HIV/AIDS in Africa: Practical Guidance

for Programs, have been written and widely circulated and presented at multiple forums.These documents have assisted USAID missions and other decision makers to improvetheir MTCT and HIV and nutrition strategies. In addition, through consultative research,Zambia, Zimbabwe, Malawi, and South Africa have all improved program approaches forMTCT.

AFR/SD and other partners have supported the Commonwealth Regional HealthCommunity Secretariat (CRHCS) in East and southern Africa to develop a regionalHIV/AIDS strategy to expand and accelerate the response to the epidemic in the region.This strategy was adopted by the health ministers in 14 countries and is now beingoperationalized at the country level.

With AFR/SD funding, CRHCS developed a tool to improve health policy developmentand monitoring. This guide was tested during a policy advocacy and monitoring training.CRHCS has adopted this guide and will use it as they start to monitor policies in each ofits 14 member countries in East and southern Africa.


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ANNEX 2

Actions to Reduce HIV/AIDS Impact on Each Sector

The following are illustrative lists of actions that key ministries can take to reduce theimpact of HIV/AIDS on each sector. These actions must be supported at every level and

by donors to countries.

Economic Growth

Mitigation

! Assessing the long-term impact of HIV/AIDS on economic growth and developingstrategies to minimize the impact by building manpower capacity and incentives toincrease or at least maintain productivity. This will be the most crucial factorrequiring immediate attention as it takes long time to build the skills and experiences.

! Encouraging foreign private investment to overcome the problem of reduceddomestic savings and investments at least in the short run.

! Improving resource allocation to bring it in line with the priorities of the economyand enhancing sustainability of expenditures financed through external sources.

! Establishing a system of monitoring the utilization of financial and manpowerresources to ensure their best use.

! Enhancing competitiveness in the international market for domestic products.Care and Support

! Assessing the impact on household levels and the existing coping mechanisms inorder to improve these and reduce the stress at the community levels.

!Establish Resources Transfer Mechanisms to support the decentralizedimplementation of HIV/AIDS care and prevention and poverty reduction programs.

! Adapting microenterprise and income generation programs to meet the needs of thoseaffected by HIV/AIDS.

Risk Reduction

! Developing and implementing policies and programs to reduce gender inequities.! Formulating and accelerating the implementation of Poverty Reduction Strategies

particularly for the high-risk groups (youth/orphans, commercial sex workers, mobileand displaced populations).

!Improving access to resources and income among vulnerable groups.

! Decreasing unemployment and underemployment.! Increasing women's empowerment.! Developing vocational training and job skills programs for youth.


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Democracy and Governance

The following is the list of possible DG activities that could contribute to HIV/AIDSmitigation and prevention:

Mitigation

! Strengthening national political commitment to fighting the disease.! Implementing civil service reforms to improve the availability of skilled manpower.! Strengthening civil society and community mobilization.! Working with local and national leaders to reduce stigma.! Strengthening management capacity and governance and financial management of

key ministries such as health and education.

Care and Support

! Encouraging and facilitating decentralization and community empowerment.! Improving human rights and legal frameworks, particularly those for women, people

living with HIV/AIDS and vulnerable children.! Educating and sensitizing judicial systems on HIV, human rights, and stigma.Risk Reduction

! Strengthening the information availability.! Allowing open dialogue on the issues by policy makers.! Facilitating womens empowerment.! Promoting social justice, respect for human rights and rule of law.! Establishing democratic process, a system of checks and balances and giving voice to

the voiceless.


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Education

Mitigation

Assessing the impact of HIV/AIDS internally on the capacity of the education sectorand externally on the students and their learning capacity using the education toolkit.

Generating commitment among the concerned officials to take speedy actions. Preparing an action plan to reduce the impact on the sector and on the delivery of

education.

Implementing and evaluating the action plan over the next five years with particularfocus on:

Strengthening the implementation capacity of the sector in light of HIV/AIDSespecially training of teachers and better use of financial resources.

Protecting the teachers and students from the spread of HIV/AIDS. Providing basic education and social and psychological support to vulnerable

groups such as orphans and girls through the school system.

Including life skills and HIV/AIDS education in school curricula.Care and Support

Strengthening schools to play multiple roles in prevention and care for thecommunity.

Adopting different innovative means of delivering education to children in affectedareas.

Mobilizing communities for providing education particularly in high-risk areasRisk Reduction

Expanding basic and non-formal education that includes life skills and health andHIV education, particularly for girls.

Providing adequate nutrition to children for reducing their vulnerability andenhancing their learning ability.

Expanding non-formal education and linking it to youth livelihood to reduceunemployment and poverty among vulnerable groups. Stronger focus on technologytraining.

Strengthening the education system to reach the communities particularly in hightransmission areas and high-risk groups. This is important both for high and lowprevalence countries.

Mobilizing large resources to undertake the expansion of education particularly forgirls on an emergency basis or to help countries develop an education Marshall Plan.


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Agriculture and Natural Resource Management

Mitigation

Assessing the impact of HIV/AIDS on natural resource management sectors. Generating commitment among policy makers and implementers. Developing and implementing an adequate response to HIV/AIDS such as:

Sensitizing and protecting field workers. Using outreach mechanisms to convey prevention messages. Training additional workers to mitigate the impact on manpower. Helping mobilize and organize communities for undertaking mitigation and

prevention measures.

Risk Reduction

Encouraging better use of natural resource management to reduce rural to urbanmigration.

Increasing employment and business opportunities for youth and women in agro-business.


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Health

Mitigation

Assessing HIV/AIDS impact on the health systems ability to deliver basic servicesusing the health toolkit.

Generating commitment at each level of administration to undertake measures tostrengthen the health sector and implement appropriate responses.

Developing a response to the epidemic and implementing key actions during the nextfive years, particularly:

Rapidly expanding health education Training health manpower to replace lost workers Protecting health workers and clients from the spread of the disease Providing in-service training to health workers Providing gloves and needles, etc. Treating STDs Providing voluntary counseling and testing Preventing mother-to-child transmission Ensuring blood safety Making drugs available to treat HIV/AIDS and other infections using defined

policies that make the access to drugs and services equitable.

Risk Reduction

Making adequate food and nutrition available, particularly to vulnerable groups,for reducing the chances of infections.

Strengthening health education programs, particularly for youth. Improving water and sanitation facilities. Implementing health reforms to expand and strengthen access to packages of

HIV/AIDS prevention services.

Defining the role of the private sector and non-governmental organizations in theexpanding health system and redefining the government's role to provide publichealth and regulatory mechanisms.


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Annex 3

Summary of Toolkits for Responding to HIV/AIDS

Toolkits for developing and Implementing Multisectoral Response

A number of tools have been developed to assist different sectors determine the extent ofthe HIV/AIDS problem and design strategies to find and implement solutions.Unfortunately, the lack of available resources and inadequate inter-agency coordinationhas limited the use of these toolkits to date. The following list summarizes the tools thatare available and briefly describes how they can be used.

AIDS Toolkits: This is for governments to use to understand the epidemic, why theyneed to get involved and how to plan a response. This toolkit is comprised of four genericpieces: Understanding HIV/AIDS, Why HIV/AIDS is a Government Issue,HIV/AIDS andMinistry Employees, and Planning Tools, and targeted pieces to specific government

ministries. These toolkits were designed to assist government ministries or departmentsdevelop sector-specific responses to the HIV/AIDS pandemic affecting their country.These toolkits have been designed for government ministry officials and programmanagers to use to gain active commitment of their leadership, to prioritize activities andto engage the assistance of experts with knowledge of HIV/AIDS and planning skills. Amechanism is being explored for ways that the University of Natal/HEARD division orother groups with experience in applying these tools, can provide initial consultation andassistance with interested ministries.

Democracy and Governance Toolkit: The purpose of this toolkit is to provide acollection of tools for use in applying democracy and governance (D&G) approaches to

HIV/AIDS work. It is organized around key D&G concepts that have direct applicationto specific needs in HIV/AIDS programming and is intended to assist current efforts toscale up responses to the pandemic and increase access to prevention and care servicesthrough collaboration at individual, community, and national levels. The toolkit seeks toovercome traditional barriers by focusing on areas where HIV/AIDS and D&G naturallycomplement one another. The toolkit is divided into five sections: Democratic principlesand practices, Rule of Law, Increasing Citizen participation, Increased capacity, andenhanced flow of information. Specific tools for relating these D&G focus areas withHIV/AIDS work are included at the end of each section. The toolkit is designed fordonor organizations, civil society, government, and the private sector.

Local Government Toolkit: This toolkit was developed to assist local government inSouth Africa define their role in the partnership Against AIDS and to initiate theirresponses to the epidemic. Although designed for local governments in South Africa, thetools can be adapted for other contexts that require developing a response to HIV/AIDS.It can be used with local government officials and those responsible for developingHIV/AIDS responses in any country. This Local Government toolkit can also be usedwith other complementary tools such as workplace program guidelines. This toolkit wasdesigned for program managers and officials to use to develop an HIV/AIDS response at


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the local government level. Users should be familiar with HIV/AIDS issues to utilizefully the tools in this kit.

HIV/AIDS Toolkit: UNAIDS declared that effective responses to HIV/AIDS arecharacterized by political commitment from community leadership up to a countrys

highest political level. This toolkit is designed to assist activists determine whether andhow to build political commitment as a key step in combating HIV/AIDS in theircountries. The toolkit considers questions around political commitment and whatconscious actions are necessary to increase political commitment for effective HIV/AIDSpolicies. The focus of the toolkit is sub-Saharan Africa, but the principles andapproaches are relevant to other regions of the world. This toolkit is divided into fivecomponents:Building Political Commitment, Measuring Political Commitment, AIDSImpact Model, Building Commitment at Subnational Levels, and Building Commitmentthrough Broadening Participation in the Policy Process. Each is a stand-alone piece butthey all interact together to form a comprehensive set of tools and approaches that can beused to develop political commitment at various levels. Each component highlights

lessons learned, provides real-world examples, and provides a references and resourcessection at the end. As activists and program planners consider how to respond HIV/AIDSepidemic, this toolkit can help to guide them through a process to gauge and buildpolitical commitment toward developing this greater response to the epidemic. Thoughmany of the practical tools needed to complete the interventions are not included, thisdocument tells the reader where they can be obtained and what resources are needed toimplement them.

AIDS, Poverty Reduction and Debt Relief: A Toolkit for Mainstreaming HIV/AIDSProgrammes into Development Instruments: This toolkit is for people who areresponsible for getting the HIV/AIDS agenda into the broader development efforts of thecountry. Through definitions of the relation between HIV/AIDS and poverty and caseexamples, this document is designed to help country officials and their partners prepareand negotiate effectively the need to include scaled-up HIV/AIDS programs in allpoverty reduction strategy papers and instruments of debt relief under the enhanced HPICinitiative. This toolkit is designed as a resource for training at the country and sub-regional levels for country teams comprised of government, NGO and donor agencyofficials. Its purpose is to enable these country teams to develop useful materials toinclude HIV/AIDS programs in poverty reduction strategies. More work will be done tocontinually improve the toolkit and the processes for building coalitions of partners insupport of national responses to HIV/AIDS.

mutuku musembi

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